1
FEHB Program Carrier Letter All Community-Rated Carriers
U.S. Office of Personnel Management Healthcare and Insurance
Letter No. 2015-11 Date: June 5, 2015
Fee-for-service [n/a ] Experience-rated HMO [ n/a ] Community-rated HMO [ 9 ]
SUBJECT: Claims Data Requirements for Non-Traditional
Community-Rated Carriers
Medical Loss Ratio (MLR) Claims Data Requirement
Beginning in 2013, all carriers who are not mandated by their state to use Traditional
Community Rating (TCR) to rate the Federal Employees Health Benefits Program (FEHBP) are
required to follow the medical loss ratio (MLR) requirements. This letter provides detailed
instructions to non-TCR carriers regarding claims data submission to the Office of Personnel
Management’s (OPM) Office of the Inspector General (OIG).
All MLR carriers must submit to the OIG detailed FEHBP claims data used in its MLR
calculation. The data should include FEHBP claims incurred during calendar year 2014, and
paid through June 30, 2015. No other claims will be considered. Completion factors should not
be included. Only FEHBP claims associated with benefits covered may be included in the MLR
claims. Please read the attached specifications and provide the supporting documentation by
September 30, 2015. The information may be used for audit and investigative purposes only.
Rate Build Up Claims Data Requirement
Carriers using Adjusted Community Rating (ACR) to rate the FEHBP are required to backup and
save claims data used in the FEHBP rate build up. Carriers should use the data layout and
specifications included in this letter and attachments to meet this requirement. Carriers must
submit Attachment 3 from this letter with the information related to the FEHBP rate build up
claims data. Additionally, the carrier is required to submit an updated copy of Attachments 1
and 2 illustrating the carrier’s rate build up claims data file layout. Carriers are not required to
submit the actual rate build up claims data to the OIG. Carriers must keep this data and
make it available during OIG rate build up audits. The claims data for the FEHBP should be
downloaded from a central database at the time the rates are developed. The information may be
used for audit and investigative purposes only. We remind carriers to retain the data in order to
avoid the potential for future audit findings.
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Questions regarding audit objectives or requirements should be directed to Jim Tuel, Jr., Chief,
Community-Rated Audits Group on (724) 741-0713 or at [email protected]. Technical
questions regarding technical requirements should be directed to the OIG -Technology HELP
DESK at [email protected].
Sincerely,
John O’Brien
Director
Healthcare and Insurance
Attachments
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UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
OFFICE OF THE INSPECTOR GENERAL (OIG)
OFFICE OF AUDITS
COMMUNITY-RATED AUDITS GROUP
CLAIMS DATA REQUIREMENTS
FOR
NON-TRADITIONAL COMMUNITY RATED CARRIERS
ATTACHMENTS
DUE DATE: SEPTEMBER 30, 2015
Contact for questions:
Nekitra T. Tuell, OPM/OIG
1900 E Street, NW, Room 6400
Washington, D.C. 20415-1100
Office Number (202) 606-0120
Fax Number (202) 606-4823
E-mail: [email protected]
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INSTRUCTIONS FOR FORMATTING AND SUBMITTING CLAIMS
OIG has a mandatory claims data layout that must be used. Please contact Nekitra Tuell at
[email protected] to receive the mandatory claims data layout in Excel.
Attachments 1 and 2 contain the mandatory data fields that are required for medical claims
(professional, facility, dental, etc.) and for pharmaceutical claims, respectively.
NOTE: If certain mandatory fields are not captured or are unavailable, please contact Nekitra
Tuell at [email protected] prior to the submission. If data for certain fields are
unavailable, please include the field, but leave the field empty. Please include any additional
fields that you feel contain pertinent information at the end of the mandatory fields. If any
required fields are missing and the OIG has not been contacted, your claims submission will be
considered incomplete.
Please return an updated copy of Attachments 1, 2, and 3 with your data submission. Normally
these files should contain a separate record for each line/charge that is contained in each claim.
For carriers that use a method other than actual, adjudicated claims (i.e., encounters, utilization,
etc.), please include the detailed experience data you used to determine the experience factor for
the FEHBP’s MLR numerator.
REQUIRED DOCUMENTATION
All carriers are required to submit Attachments 1, 2, and 3. However, only carriers using
the MLR methodology are required to submit claim files to the OIG.
Claims Data Submission – For MLR Carriers only, provide in an OIG-approved file format as
follows:
Fixed Width Flat File (Text) Note: The OIG should receive a separate file for medical and pharmaceutical
claims.
Any other format must be pre-approved by contacting the OIG
Attachments 1 and 2 – For all Carriers, update Attachments 1 and 2 with any additional fields
included in the claims data submission (if applicable).
Attachment 3 – For all Carriers, complete the Media Specification Form, Attachment 3, for each
claims data file submitted.
Data Dictionary – For all Carriers, submit a data dictionary that includes code sets and
definitions for fields as required below:
Field # 11 - Patient Relationship Code
Field # 29 - Place of Service Code
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Field # 30 - Type of Service Code
Field(s) # 33, 34, 36, 38 - Diagnosis Code - Please provide a list of any
non- ICD codes used for these fields
Field # 51 - Performing Provider Specialty Code
CLAIMS DATA SUBMISSION REQUIREMENTS
Effective immediately, all Community-Rated carriers that submit Federal Employees Health
Benefits Program claims data to the Office of Personnel Management (OPM), Office of the
Inspector General (OIG), must do so using a Secure File Transfer Protocol (SFTP) account.
Submitting claims data using any other method (i.e., DVD, flash drive, secure mail, FTP), is no
longer permitted.
Existing File Transfer Protocol (FTP) Account Holders:
All existing FTP account holders will need to obtain a SFTP account immediately.
New SFTP Account Holders:
All Community-Rated carriers will be required to set up a SFTP account by August 3, 2015.
SFTP accounts are now required for MLR claims submissions which will be due on September
30, 2015.
The OPM/OIG SFTP transfer consists of several steps involving, but not limited to, OPM
firewall access, OIG server user ID and password generation, and data compression and
encryption. To acquire a SFTP account through OPM/OIG, please follow the steps outlined
below.
OIG SFTP Transfer Steps:
All SFTP technical questions or issues should be directed to the:
OIG SFTP ADMINISTRATORS
o Rohit Kapoor, Chief, OPM OIG Information Systems Technology Group,
202-606-1280 or at [email protected]
o Jason Cooper, IT Specialist, OPM OIG Information Systems Technology Group,
202-606-9505 or at [email protected]
1. Public IP Address of Internal Server – To gain access through the OPM Firewall, the
carrier must provide the public IP address of the server sending the file to OPM. Once
this information is obtained and ready to be given to OPM/OIG, proceed to Step 2.
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2. Initiate Account Set-up – To request a SFTP account or update an existing FTP account,
contact the OIG SFTP Administrators via phone or email (previously listed). Provide
them with the public IP address of the server sending the file to OPM. This information
will be entered into the OPM firewall for access.
3. Obtain Username and Password - Once firewall access has been obtained, the OIG SFTP
Administrators will work with the point of contact from the carrier to provide a username
and password to the SFTP server.
4. File Specifications – All transmitted files must be in ASCII or SAS format based on the
agreed upon fixed length format.
5. Select Encryption Software - The OIG SFTP process requires that all transmitted data be
compressed and encrypted. The carrier must use the same software as the OIG. File
encryption software performs data compression and data encryption. Coordinate with the
OIG SFTP Administrator to determine which software will be used. The OIG SFTP
server can accept:
o PGP (or GPG) Encryption (preferred method), or
o PKZIP Encryption (using highest encryption level possible)
6. File Testing - Coordinate with the OIG SFTP Administrators to transmit test files. Once
testing has been completed, the carrier will be assigned a date and time for the initial data
transfer and recurring transmissions. The OIG prefers that the carrier send an email to
[email protected] and [email protected] each time a test file has been
transmitted.
7. File Naming Conventions – We request the following naming conventions be placed on
the transmitted files:
Medical Claims
o Medical.CLAIMS.PlanCode.Y2015.pgp [2015 is the time frame the file covers
not when it was transmitted] [Plan Code is the two digit alphanumeric plan code
assigned by the FEHBP.] Example: Medical.CLAIMS.AZ.Y2015
Pharmacy Claims
o Pharmacy.CLAIMS.PlanCode.Y2015.pgp [2015 is the time frame the file covers
not when it was transmitted] [Plan Code is the two digit alphanumeric code
assigned by the FEHBP.] Example: Pharmacy.CLAIMS.AZ.Y2015
8. Confirmation Email – We request that an email be sent after each file/group of files has
been transmitted. The purpose is to notify us that a specific file(s) has been transmitted
and to provide us with the file name, the necessary record counts and amounts necessary
to confirm that the complete file(s) was received. For example, we should receive an
email every time a claim file is transferred to us. The email should include the name of
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the file, number of records in the file, and total amount paid by plan. We request that the
following OIG staff members be copied on each transmission email:
o OIG-Technology Helpdesk ([email protected])
o Nekitra Tuell ([email protected])
o Lindsay Haber ([email protected])
* Do not include the time in the date fields
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Attachment 1
US OPM, OFFICE OF THE INSPECTOR GENERAL, OFFICE OF AUDITS
MANDATORY MEDICAL CLAIM FIELD REQUIREMENTS
Field
#
Field Name Field
Type
Length Field Description and Code
Value Sets
1 Plan Code Character
02 The two digit alphanumeric plan
code assigned by the FEHB. (e.g.
JP, CY, 63, etc.) Left justified.
2 Plan Name Character 40 Plan Name – Brochure Name (e.g.
Coventry Health Care of Kansas,
Dean Health Plan, etc.)
3 Group Number Character 12 Unique identifier for the group.
Left justified.
4 Group Name Character 40 Name of the group. Left justified.
5 Subscriber ID Number Character
12 Unique identifier of the Subscriber.
Left justified.
6 SSN-Patient Character
09 SSN of Patient, left justified with
appropriate leading zeros, no
hyphens.
7 Subscriber First Name Character 25 First name of the subscriber. Left
justified.
8 Subscriber Middle Name Character 25 Middle name of the subscriber.
Left justified.
9 Subscriber Last Name Character 25 Last name of the subscriber. Left
justified.
10
Subscriber Name Suffix Character 05 Name suffix that follows
subscriber’s last name. (e.g. Jr.,
Sr., III, IV, etc.) Left justified.
11 Unique Patient
Identifier Code/Number
Character
02 Unique alphabetic code (A-Z) or
sequential number to differentiate
each person covered on this
contract. Left justified.
12 Patient Relationship Code Character 02 Code to define/identify the
relationship of the patient to the
subscriber/contract holder. Please
provide code set for this field. Left
justified.
13 Patient ID Number Character 12 Unique identifier of the Patient.
Left justified.
14 Patient Date of Birth* Date
08 Complete Date of birth. Date
Format: YYYYMMDD.
* Do not include the time in the date fields
2
15 Patient First Name Character 25 First name of the patient. Left
justified.
16 Patient Middle Name Character 25 Middle name of the patient. Left
justified.
17 Patient Last Name Character 25 Last name of the patient Left
justified.
18 Patient Name Suffix Character 05 Name suffix that follows patient’s
last name. (e.g. Jr., Sr., III, IV,
etc.) Left justified.
19 Patient Gender Character
01 Values: F=Female; M=Male; else
Blank = unknown. Left justified.
If “blank” is used, do not add the
actual word “blank”. Please leave
the field empty.
20 FEHB Enrollment Code Character 03 Use OPM assigned 3 position
enrollment code. (e.g. 321, 322)
Left justified.
21 Claim Number Character 20 The unique number assigned to
this claim by the carrier. Left
justified.
22 Claim/Charge Line # Numeric 03 The line number assigned to this
specific charge line. If the claim
only has one charge line, the value
will usually be 1. Left justified.
23 Claim – Number of Charges Numeric
03 Total number of line items/charges
for this claim. Left justified.
24 Claim Type (I/P,O/P,
Professional)
Character
01
Indicates the type of claim being
reported.
Values: I = Inpatient Hospital; O
= Outpatient Hospital; P =
Physician. Left justified.
Note:
If a claim has any value other than
I, O, or P, please leave the field
empty. Do not add the actual
word “blank”.
25 Claim Disposition/Status
Code
Character
01 Code to indicate the status of the
record such as original claim,
adjustment, void/reversal, etc.
Please use the codes (1-4) ► See
* Do not include the time in the date fields
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Attachment 4 for Code Value
Definitions.
26 First Date of Service * Date
08 The first incurred date of service
for the charge. Date Format:
YYYYMMDD. Left justified.
27 Last Date of Service* Date
08 The last date of service/discharge
date for the charge. Date Format:
YYYYMMDD. Left justified.
28 Number of Services/Days Numeric
04 The number of times the same
service, etc. was rendered. Left
justified.
If this field is populated then field
# 28 should be populated.
29 Service Units Code Character
02 Identifies the unit of measurement
for the Number of Services field.
(DA, DH, MA, MJ, MO, UN, VS,
WK, YR) else Blanks ► See
Attachment 4 for Code Value
Definitions. Left justified.
30 Place of Service Code Character
03
Please provide code set for this
field. Left justified. This field
should be populated for all types of
claims (Inpatient, Outpatient and
Professional).
31 Type of Service Code Character
03
Indicates the type of service such
as Surgery, Anesthesia, Diagnostic
Radiology, etc. Please provide
code set for this field. Left
justified.
32
Diagnosis Code Type (1) Character
01 The primary diagnosis for the
charges on this line.
9 = ICD-9 codes; 0 = ICD-10
codes; S = Special Codes by this
carrier; Blank = no diag code
reported. Left justified. If “blank” is used, do not add the
actual word “blank”. Please leave the
field empty.
33
Diagnosis Code (1)
[=Principal Diag for Facil]
Character
08
For Facility claims, provide the
Principal Diagnosis Code followed by the Admitting
Diagnosis Code and first 2 Other
Diagnosis Codes. For Professional
claims, provide the first 4
* Do not include the time in the date fields
4
Diagnosis Codes for the charge
line. Left justified, no decimal.
1st position = (0-9, V or E) and
field length 3 to 5 positions for
ICD-9 codes.
The 8th position should always be
the Present on Admission (POA)
Indicator. Values = Y, N, U, W, 1.
34 Diagnosis Code Type (2)
Character
01 9 = ICD-9 codes; 0 = ICD-10
codes; S = Special Codes by this
carrier; Blank = no diagnosis code
reported. Left justified.
If “blank” is used, do not add the
actual word “blank”. Please leave the
field empty.
35 Diagnosis Code (2)
[=Admitting Diag for Facil]
Character
08 Please provide a list of any non
ICD codes used for these fields.
Left justified.
36 Diagnosis Code Type (3)
Character
01 9 = ICD-9 codes; 0 = ICD-10
codes; S = Special Codes by this
carrier; Blank = no diagnosis code
reported. Left justified.
If “blank” is used, do not add the
actual word “blank”. Please leave the
field empty.
37 Diagnosis Code (3) Character
08 Please provide a list of any non
ICD codes used for these fields.
Left justified.
38 Diagnosis Code Type (4)
Character
01 9 = ICD-9 codes; 0 = ICD-10
codes; S = Special Codes by this
carrier; Blank = no diagnosis code
reported. Left justified.
If “blank” is used, do not add the
actual word “blank”. Please leave the
field empty.
39 Diagnosis Code (4) Character
08 Please provide a list of any non
ICD codes used for these fields.
Left justified.
40
Procedure Code Type
Primary
Character
01 Indicates the type of code set that
appears in the Procedure Code
field.
Values: (C, D, H, I, J, R, S,
* Do not include the time in the date fields
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Blank). C =CPT-4 Codes; D =
American Dental Assoc. Codes; H
= HCPCS Codes; I = ICD-9
Procedure Codes; J = ICD-10
Procedure Codes; R = Revenue
Code; S = Special Codes by this
carrier; or Blanks = Unknown.
Left justified. If “blank” is used, do
not add the actual word “blank”.
Please leave the field empty.
41 Procedure Code
Primary
Character
07 Primary Procedure. HCPCS or
CPT-4 Medical Procedure Code or
the ADA Dental Procedure Code.
Blanks or ICD-9 for Facility
claims. Left justified. Please
provide a list of any other codes
used for this field.
42 Procedure Modifier Code
(1)
Character
02 Code that indicates additional
information about the procedure
(i.e. a specific body part, who
performed the procedure, etc.)
CPT-4 Medical Procedure Code
Modifier (Blanks, 21-99, A1-VP)
for the Primary Procedure. This
field can be populated for facility
and professional claims. Left
justified.
43 Procedure Modifier Code
(2)
Character
02 Second Procedure Code Modifier
for the Primary Procedure. Left
justified.
44 Procedure Modifier Code
(3)
Character
02 Third Procedure Code Modifier for
the Primary Procedure. Left
justified.
45 Procedure Modifier Code
(4)
Character
02 Fourth Procedure Code Modifier
for the Primary Procedure. Left
justified.
46 Patient Discharge Status
Code
Character
02 HIPAA numeric values (00-72) for
facility claims only, otherwise
Blanks. If “blank” is used, do not
add the actual word “blank”. Please
leave the field empty.
► See Attachment 4 for Code
* Do not include the time in the date fields
6
Value Definitions. Left justified.
47 Performing Provider ID Character
10 ID assigned to the performing
provider for the service. Left
justified.
48 Performing Provider ID
Type
Character 02 Blank=Not Specified
Ø1=Medicare
Ø2=Medicaid
Ø3=UPIN
Ø4=State License
Ø5=Champus
Ø6=Health Industry Number
(HIN)
Ø7=Federal Tax ID
Ø8=Drug Enforcement
Administration (DEA)
Ø9=State Issued
1Ø=Carrier Specific
11= Social Security Number
12=Federal Tax Payers
Identification Number (FTIN)
99=Other
Left justified.
If “blank” is used, do not add the
actual word “blank”. Please leave the
field empty.
49 Performing Provider - NPI
ID
Character
10 National Provider Identifier (NPI)
reported by the Performing
Provider. Left justified.
50 Performing Provider Name Character
40 Name of the Performing Provider
(Last Name at a minimum). Left
justified. Free form or First
Name-Middle Name-Last Name.
51 Performing Provider Zip
Code
Character
09 Zip code of where the service or
care was rendered. Left justified.
52 Performing Provider
Specialty Code
Character
07 Code that identifies the specialty of
the Performing Provider. Please
provide code set for this field. Left
justified.
53 Performing Provider
Network Status
Character 01
Code to indicate whether the
performing provider is in the
network = (Y), out of the network
= (N). Left justified.
54 Debarred Provider - Character 01 Indicate whether provider is
* Do not include the time in the date fields
7
Indicator debarred (Y = Yes; N=No; Blank
= Unknown/Unavailable). Left
justified.
If “blank” is used, do not add the
actual word “blank”. Please leave the
field empty.
55 Debarred Provider -
Payment Reason Code
Character
01 (C,D,G,M,U,X,Blank) ► See
Attachment 4 for Code Value
Definitions. Left justified.
56 Date Paid * Date
08 Date the carrier paid the claim.
Date Format: YYYYMMDD
57 Payee Character
01 Code to indicate the recipient of
the insurance payment. P =
Provider; S = Subscriber; T = 3rd
party. Left justified.
58 Billed Charges Amount Amount PIC X,
PIC
S9(07)V99
Total amount charged by the
performing provider for the service
for this line. First position is the
sign followed by 9 digits with an
implied decimal before the last 2
digits.
Ex. -999999999 with implied
decimal before last 2 digits. Note:
Only add the sign if the value is
negative. If the value is positive,
there is no need for a sign, hold the
first position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating with an
amount.
59 Allowed/Covered
Amount
Amount PIC X,
PIC
S9(07)V99
The amount of the billed charges
that are covered by the carrier for
this line. First position is the sign
followed by 9 digits with an
implied decimal before the last 2
digits.
Ex. -999999999 with implied
decimal before last 2 digits. Note:
Only add the sign if the value is
negative. If the value is positive,
* Do not include the time in the date fields
8
there is no need for a sign, hold the
first position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating with an
amount.
60 Medicare Payment
Disposition Code
Applicable to whichever one
has primary.
Character
01 Code to indicate if patient is
enrolled in Medicare and which
part of Medicare was primary.
Field is blank if this insurance is
primary.
A-H, J, K, N, P, U, Blank ► See
Attachment 4 for Code Value
Definitions. Left justified.
61 Other carrier – Paid
Indicator (1)
Character
02 (16, BL, C1, MA, MB, MU, NF,
SP, SU, WC) otherwise Blanks if
this carrier paid as Primary. ►
See Attachment 4 for Code Value
Definitions. Left justified.
62 Other Carrier -Amount Paid
(1)
Amount
PIC X,
PIC
S9(07)V99
Report the amount paid by the
primary other insurance carrier
when applicable on this line item.
First position is the sign followed
by 9 digits with an implied decimal
before the last 2 digits. Ex. -
999999999 with implied decimal
before last 2 digits. Note: Only
add the sign if the value is
negative. If the value is positive,
there is no need for a sign, hold the
first position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified.
Please populate with zeros instead
of blanks if not populating with an
amount.
63 Other carrier – Paid
Indicator (2)
Character
02 (16, BL, C1, MA, MB, MU, NF,
SP, SU, WC) otherwise Blanks if
this carrier paid as Primary. ►
See Attachment 4 for Code Value
Definitions. Left justified.
* Do not include the time in the date fields
9
64 Other Carrier-Amount Paid
(2)
Amount PIC X,
PIC
S9(07)V99
Report the amount paid by a
second other insurance carrier
when applicable who paid prior to
this carrier on this line item. First
position is the sign followed by 9
digits with an implied decimal
before the last 2 digits. Ex. -
999999999 with implied decimal
before last 2 digits. Note: Only
add the sign if the value is
negative. If the value is positive,
there is no need for a sign, hold the
first position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified.
Please populate with zeros instead
of blanks if not populating with an
amount.
65 Other Insurance/Medicare
Allowed Amount
Amount PIC X,
PIC
S9(07)V99
Report the Other Carrier allowed
amount or the Medicare priced
amount for this line. First position
is the sign followed by 9 digits
with an implied decimal before the
last 2 digits. Ex. -999999999 with
implied decimal before last 2
digits. Note: Only add the sign if
the value is negative. If the value is
positive, there is no need for a
sign, hold the first position with a
space. Additionally, places need to
be held by digits not spaces in the
totals. Left justified.
Please populate with zeros instead
of blanks if not populating with an
amount.
66 Pricing Method Code (1) Character
01 Values: (4, 5, 6, B, D, E, F, G, I,
K, L, M, N, U, V) ► See
Attachment 4 for Code Value
Definitions. Left justified.
67 Pricing Method Code (2) Character
01 Values: (4, 5, 6, B, D, E, F, G, I,
K, L, M, N, U, V) ► See
Attachment 4 for Code Value
Definitions. Left justified.
* Do not include the time in the date fields
10
68 Patient Liability Amount Amount
PIC X,
PIC
S9(07)V99
The patient’s out-of-pocket
expense for this charge on this line.
It is comprised of the remaining
calendar year deductible amount,
copayment amount and
coinsurance amount, depending on
the carrier’s benefit structure for
the service. First position is the
sign followed by 9 digits with an
implied decimal before the last 2
digits. Ex. -999999999 with
implied decimal before last 2
digits. Note: Only add the sign if
the value is negative. If the value is
positive, there is no need for a
sign, hold the first position with a
space. Additionally, places need to
be held by digits not spaces in the
totals. Left justified.
Please populate with zeros instead
of blanks if not populating an
amount.
69 Insurance Amount Paid Amount
PIC X,
PIC
S9(07)V99
The amount paid to the payee by
this insurance company for the
service on this line. First position
is the sign followed by 9 digits
with an implied decimal before the
last 2 digits.
Ex. -999999999 with implied
decimal before last 2 digits. Note:
Only add the sign if the value is
negative. If the value is positive,
there is no need for a sign, hold the
first position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating an
amount.
70 Claim - Total Billed Amount
Amount PIC X,
PIC
S9(08)V99
Report the total billed amount for
all line items for this claim. First
position is the sign followed by 10
digits with an implied decimal
* Do not include the time in the date fields
11
before the last 2 digits. Ex. -
9999999999 with implied decimal
before last 2 digits. Note: Only
add the sign if the value is
negative. If the value is positive,
there is no need for a sign, hold the
first position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating an
amount.
71 Claim - Total Covered
Charges
Amount PIC X,
PIC
S9(08)V99
Amount of the submitted charges
for all line items for this claim that
are covered by the carrier's
contract. This amount should
exclude charges billed for non-
covered services. First position is
the sign followed by 10 digits with
an implied decimal before the last
2 digits. Ex. -9999999999 with
implied decimal before last 2
digits. Note: Only add the sign if
the value is negative. If the value is
positive, there is no need for a
sign, hold the first position with a
space. Additionally, places need to
be held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating an
amount.
72 Claim - Total Amount Paid Amount PIC X,
PIC
S9(08)V99
Amount of the submitted charges
for all line items for this claim that
are covered by the carrier's
contract. This amount should
exclude charges billed for non-
covered services. First position is
the sign followed by 10 digits with
an implied decimal before the last
2 digits. Ex. -9999999999 with
implied decimal before last 2
digits. Note: Only add the sign if
* Do not include the time in the date fields
12
the value is negative. If the value is
positive, there is no need for a
sign, hold the first position with a
space. Additionally, places need to
be held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating an
amount.
73 Coinsurance Amount Amount PIC X,
PIC
S9(07)V99
The amount coinsurance due from
patient for this line. First position is
the sign followed by 9 digits with an
implied decimal before the last 2
digits.
Ex. -999999999 with implied
decimal before last 2 digits. Note:
Only add the sign if the value is
negative. If the value is positive,
there is no need for a sign, hold the
first position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating an
amount.
74 Copayment Amount Amount PIC X,
PIC
S9(07)V99
The copayment amount due from
the patient for this line. First
position is the sign followed by 9
digits with an implied decimal
before the last 2 digits. Ex. -
999999999 with implied decimal
before last 2 digits. Note: Only add
the sign if the value is negative. If
the value is positive, there is no
need for a sign, hold the first
position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating an
amount.
* Do not include the time in the date fields
13
75 Deductible Amount Amount PIC X,
PIC
S9(07)V99
The deductible amount due from
the patient for this line. First
position is the sign followed by 9
digits with an implied decimal
before the last 2 digits. Ex. -
999999999 with implied decimal
before last 2 digits. Note: Only
add the sign if the value is
negative. If the value is positive,
there is no need for a sign, hold the
first position with a space.
Additionally, places need to be
held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating an
amount.
76 Total Amount Paid by all
Sources
Amount PIC X,
PIC
S9(07)V99
This field should be the sum of the
carrier, other insurance and
member amount paid fields for this
line. First position is the sign
followed by 9 digits with an
implied decimal before the last 2
digits. Ex. -999999999 with
implied decimal before last 2
digits. Note: Only add the sign if
the value is negative. If the value is
positive, there is no need for a
sign, hold the first position with a
space. Additionally, places need to
be held by digits not spaces in the
totals. Left justified. Please
populate with zeros instead of
blanks if not populating an
amount.
* Do not include the time in the date fields
1
Attachment 2
US OPM, OFFICE OF THE INSPECTOR GENERAL, OFFICE OF AUDITS
MANDATORY PHARMACEUTICAL CLAIM FIELD REQUIREMENTS
Field # Field Name Field
Format
Length
Field Description
1 Plan Code Character 02 The two digit alphanumeric plan code assigned
by the FEHB. (e.g. JP, CY, 63, etc.) Left
justified.
2 Plan Name Character 40 Plan Name – Brochure Name (Coventry Health
Care of Kansas, Dean Health Plan, etc.)
3 Group Number Character 15 Unique identifier for the group. Left justified.
4 Group Name Character 40 Name of the group. Left justified.
5 Subscriber ID
Number
Character 12
Unique identifier of the Subscriber. Please
coordinate the medical and prescription drug
files subscriber IDs. Left justified.
6 SSN-Patient Character
09 SSN of Patient, left justified with appropriate
leading zeros, no hyphens.
7 Subscriber First
Name
Character 25 First name of the subscriber .Left justified.
8 Subscriber Middle
Name
Character 25 Middle name of the subscriber. Left justified.
9 Subscriber Last
Name
Character 25 Last name of the subscriber. Left justified.
10 Subscriber Name
Suffix
Character 05 Name suffix that follows subscriber’s last name.
(e.g. Jr., Sr., III, IV, etc.) Left justified.
11 Patient Identifier Character 02 Unique alphabetic code (A-Z) or sequential
number to differentiate each person covered on
this contract. Left justified
12 Patient First Name Character 25 First name of the patient. Left justified.
13 Patient Middle
Name
Character 25 Middle name of the patient. Left justified.
14 Patient Last Name Character 25 Last name of the patient. Left justified.
15 Patient Suffix Character 05 Name suffix that follows patient’s last name.
(e.g. Jr., Sr., III, IV, etc.) Left justified.
16 Patient ID Number
Character 12 Unique identifier of the patient. Please
coordinate the medical and prescription drug
files patient IDs (if applicable). Left justified.
17 Patient Date of
Birth*
Date 08 Complete date of birth. Date Format:
YYYYMMDD
18 Patient Gender Character 01 F=Female; M=Male; else Blank = unknown.
Left justified. If “blank” is used, do not add the
actual word “blank”. Please leave the field
empty.
* Do not include the time in the date fields
2
19 Claim Number Character 20
The unique number assigned to each prescription
by the carrier. Left justified.
20
Mail Order/Retail
Claim Code
Character 01 Values: M=Mail Order; R=Retail Pharmacy in
Network; S= Specialty; O=Other. Left justified.
21 Prescription Number Character 20 Prescription number assigned by the pharmacy.
Left justified.
22
Date Filled* Date 08
Date the drug was dispensed by the pharmacy.
Date Format: YYYYMMDD
23 Date Prescription
Written
Date 08 Date the prescription was written as submitted
by pharmacy. Date Format: YYYYMMDD
24
Date Processed Date 08 Date the drug was processed by the pharmacy.
Date Format: YYYYMMDD
25 NDC Number Character 15 National Drug Code (NDC) for the dispensed
drug. Left justified.
26 Drug Name Character 30 Name of the drug dispensed. Left justified.
27
Drug Strength Character 10 Drug strength (i.e., 500MG, 0.5%, etc.). Left
justified.
28 Unit of Measure Character 02 Indicates the dosage form of the drug dispensed
“space” – Not specified
ML – Milliliters
GM – Grams
EA – Each
Left justified.
29 Generic/Name Brand
Code
Character 01 Code to indicate if the drug dispensed is G =
Generic or B = Name Brand. Left justified.
30 Compound Indicator Character 01 Indicates if the drug dispensed is a compound.
Left justified.
0 = unknown
1 = Not a Compound
2 = Compound
31
Formulary Indicator Character 01 Indicates if the drug dispensed is formulary. Left
justified.
0 = unknown
1 = Not Formulary
2 = Formulary
32 Refill Number Numeric 02 The number of times this prescription has been
refilled. Use zero for a new prescription.
Code identifying whether the prescription is an
original (00) or by refill number (01-99).
00 - New
01-99 - Refill number
Left justified.
* Do not include the time in the date fields
3
33
Quantity Dispensed Numeric 6 Total quantity dispensed expressed in metric
decimal units as submitted by the pharmacy.
Left justified.
34 Days Supply Numeric 03 The estimated number of days the prescription
will last. Left justified.
35 Dispensing Status Character 01 Indicates if the prescription was a partial fill or
the completion of a partial fill.
Values:
Blank = not a partial fill
P=partial fill
C= completion of partial fill
This data is submitted by the pharmacy.
Note that if a partial fill is submitted by a
pharmacy, this field must be submitted with a 'p'
or 'c' value. Left justified.
36 Dispense As Written Character 01 Code indicating whether or not the prescriber’s
instructions regarding generic substitution were
followed. Values: Y= Yes; N=No; else Blank =
unknown. Left justified. If “blank” is used, do
not add the actual word “blank”. Please leave
the field empty.
37 Pharmacy NABP
Number
Character 15 Unique ID number assigned by the National
Association of Boards of Pharmacy (NABP) to
the pharmacy that dispensed the prescription.
Left justified.
38 Pharmacy NPI Character 10 10 Digit Pharmacy NPI number as assigned by
the Centers for Medicare and Medicaid Services.
If Pharmacy not NPI field will = spaces. Left
justified.
39 Pharmacy NCPDP Character 10 Provide the pharmacy’s NCPDP ID number.
Left justified.
40 Pharmacy Name Character 35 Name of the pharmacy that dispensed the drug.
Left justified.
41 Pharmacy Zip Code Character 09
Zip code of the pharmacy location that dispensed
the drug. Left justified.
42 Prescribing
Physician ID
Character 15 ID assigned to the prescribing physician for the
drug dispensed. Left justified.
43 Prescriber ID Type Character 05 Identifies the type of ID being submitted in the
Prescriber ID field.
Values:
Blank=Not Specified
Ø1=National Provider Identifier (NPI)
Ø2=Medicare
* Do not include the time in the date fields
4
Ø3=Medicaid
Ø4=UPIN
Ø5=NCPDP Provider ID
Ø6=State License
Ø7=Champus
Ø8=Health Industry Number (HIN)
Ø9=Federal Tax ID
10=Drug Enforcement Administration (DEA)
11=State Issued
12=Carrier Specific
99=Other
Left justified. If “blank” is used, do not add the
actual word “blank”. Please leave the field empty.
44 Prescribing
Physician NPI
Character 10 ID assigned to the prescribing physician for the
drug dispensed. Provide the physician’s
National Provider ID (NPI). Left justified.
45 Prescribing
Physician Name
Character 35 Name of the Prescribing Physician (Last Name
as a minimum). Left justified.
46 Date Paid * Date 08
Date the carrier paid for the dispensed drug.
Date Format: YYYYMMDD
47 Payee Character 02
Code to indicate the recipient of the insurance
payment. P = Provider; S = Subscriber; T = 3rd
party. Left justified.
48 Ingredient Cost Amount PIC X, PIC
S9(07)V99
Cost of the ingredient that was dispensed.
First position is the sign followed by 9 digits
with an implied decimal before the last 2 digits.
Ex. -999999999 with implied decimal before last
2 digits. Note: Only add the sign if the value is
negative. If the value is positive, there is no need
for a sign, hold the first position with a space.
Additionally, places need to be held by digits not
spaces in the totals. Left justified. Please
populate with zeros instead of blanks if not
populating an amount.
49 Client Pricing Cost
Basis
Character 02 Code indicating the method by which ingredient
cost submitted is calculated based on client
pricing.
Values: Blank = Not Specified
01 = AWP
1P = Pre-settlement AWP
02 = ACQ
03 = Manufacturer Direct Pricing
04 = Federal upper limit
05 = Average Generic Pricing
* Do not include the time in the date fields
5
06 = U&C
07 = Submitted Ingredient Cost
08 = State MAC
09 = Unit
10 = U&C or Copay
If “blank” is used, do not add the actual word
“blank”. Please leave the field empty.
50 Amount Billed Amount PIC X, PIC
S9(07)V99
Total amount of the submitted prescription.
First position is the sign followed by 9 digits
with an implied decimal before the last 2 digits.
Ex. -999999999 with implied decimal before last
2 digits. Note: Only add the sign if the value is
negative. If the value is positive, there is no need
for a sign, hold the first position with a space.
Additionally, places need to be held by digits not
spaces in the totals. Left justified. Please
populate with zeros instead of blanks if not
populating an amount.
51 Allowed/Covered
Amount
Amount PIC X, PIC
S9(07)V99
Report the covered charges less any savings for
this line for this claim. Left justified. First
position is the sign followed by 9 digits with an
implied decimal before the last 2 digits. Ex. -
999999999 with implied decimal before last 2
digits. Note: Only add the sign if the value is
negative. If the value is positive, there is no need
for a sign, hold the first position with a space.
Additionally, places need to be held by digits not
spaces in the totals.
52 Dispensing Fee Amount PIC X, PIC
S9(07)V99
The dispensing fee submitted by the pharmacy.
First position is the sign followed by 9 digits
with an implied decimal before the last 2 digits.
Ex. -999999999 with implied decimal before last
2 digits. Note: Only add the sign if the value is
negative. If the value is positive, there is no need
for a sign, hold the first position with a space.
Additionally, places need to be held by digits not
spaces in the totals. Left justified. Please
populate with zeros instead of blanks if not
populating an amount.
53 Other Carrier
Coverage Code
Character 02
Code to indicate which, if any, other insurance
has primary liability. Field is blank if this
insurance is primary. Communicated by the
pharmacy regarding other coverage.
Values: Ø= Not Specified
1= No other coverage identified
* Do not include the time in the date fields
6
2= Other coverage exists-payment collected
3=Other coverage exists-this claim not covered
4=Other coverage exists-payment not collected
5=Managed care plan denial
6=Other coverage denied-not a participating
provider
7=Other coverage exists-not in effect at time of
service
8=Claim is a billing for a copay
Left justified.
54 Other Carrier
Amount Paid
Amount PIC X, PIC
S9(07)V99
Amount paid by another insurance carrier for
this service. First position is the sign followed by
9 digits with an implied decimal before the last 2
digits. Ex. -999999999 with implied decimal
before last 2 digits. Note: Only add the sign if
the value is negative. If the value is positive,
there is no need for a sign, hold the first position
with a space. Additionally, places need to be
held by digits not spaces in the totals. Left
justified. Please populate with zeros instead of
blanks if not populating an amount.
55 Patient Liability
Amount
Amount PIC X, PIC
S9(07)V99
The patient’s out-of-pocket expense for the
dispensed drug. First position is the sign
followed by 9 digits with an implied decimal
before the last 2 digits. Ex. -999999999 with
implied decimal before last 2 digits. Note: Only
add the sign if the value is negative. If the value
is positive, there is no need for a sign, hold the
first position with a space. Additionally, places
need to be held by digits not spaces in the totals.
Left justified. Please populate with zeros
instead of blanks if not populating an amount.
56 Insurance Amount
Paid
Amount PIC X, PIC
S9(07)V99
The amount paid to the payee by this carrier for
dispensed drug. First position is the sign
followed by 9 digits with an implied decimal
before the last 2 digits. Ex. -999999999 with
implied decimal before last 2 digits. Note: Only
add the sign if the value is negative. If the value
is positive, there is no need for a sign, hold the
first position with a space. Additionally, places
need to be held by digits not spaces in the totals.
Left justified. Please populate with zeros
instead of blanks if not populating an amount.
57 Total Amount Paid
by all Sources
Amount PIC X, PIC
S9(07)V99
This field should be the sum of the carrier, other
insurance and member amount paid fields First
position is the sign followed by 9 digits with an
* Do not include the time in the date fields
7
implied decimal before the last 2 digits. Ex. -
999999999 with implied decimal before last 2
digits. Note: Only add the sign if the value is
negative. If the value is positive, there is no need
for a sign, hold the first position with a space.
Additionally, places need to be held by digits not
spaces in the totals. Left justified. Please
populate with zeros instead of blanks if not
populating an amount.
58 Sales Tax Amount PIC X, PIC
S9(07)V99
The sale tax associated with this claim line. First
position is the sign followed by 9 digits with an
implied decimal before the last 2 digits. Ex. -
999999999 with implied decimal before last 2
digits. Note: Only add the sign if the value is
negative. If the value is positive, there is no need
for a sign, hold the first position with a space.
Additionally, places need to be held by digits not
spaces in the totals. Left justified. Please
populate with zeros instead of blanks if not
populating an amount.
59 Patient Relationship
Code
Character 02 Code to define/identify the relationship of the
patient to the subscriber/contract holder. Please
provide code set for this field. Left justified.
1
Attachment 3
US OPM, OFFICE OF THE INSPECTOR GENERAL, OFFICE OF AUDITS
MEDIA SPECIFICATIONS FORM
Please Complete and Return with each File
Insurance Company or Health Plan Name: ___________________________________
Plan Code(s):________________________________________________
File Name: __________________________________________________
(maximum 31 character name)
File Format:
___ Fixed Width Flat File (Text)
(Not Excel or Access)
Data Compression/Encryption:
___ WinZip, encryption and compression, Version 9.0 (or higher)
___ Other, explain ____________________________________
Media Type & Recording Format:
___ SFTP (All Groups)
Record Size: Record Count: Amount Control Total:
____________ _____________ $__________________
Signature: __________________________ Phone: ____________ Date: ________
Print Name: __________________________
1
Attachment 4
US OPM, OFFICE OF THE INSPECTOR GENERAL, OFFICE OF AUDITS
MANDATORY MEDICAL & PHARMACY CLAIM CODE SETS
Claim Disposition Status Code – (See Field # 24)
1 Original Claim
2 Adjustment of Original, Adjusted or Split Billed Claim
3 Extension to original facility claim (split bill)
4 Denied Claim
Service Unit Code (HIPAA codes) – (See Field # 28)
DA Days
DH Miles (Ambulance)
MA Modalities (Therapeutic Agents)
MJ Minutes (Anesthesia, etc.)
MO Month (DME Certification Loop)
UN Units (Default Value)
VS Visits
WK Week (DME Certification Loop)
YR Year (DME Certification Loop)
blank Unknown – (Do not add the actual word “blank”. Please leave the field empty).
Patient Discharge Status Code (UB-04 codes) – (See Field # 45)
00 Unknown or not applicable (not an inpatient facility claim)
01 Discharged/Transferred to Home or self-care (routine discharge)
02 Discharged/Transferred to another short term general hospital for inpatient care
03 Discharged/Transferred to SNF (Skilled Nursing Facility)
04 Discharged/Transferred to ICF (Intermediate Care Facility)
05 Discharged/Transferred to another type of facility (e.g. Cancer Hospital,
Children's Hospital) or referred for outpatient services to another facility
06 Discharged/Transferred to Home under care of Home Health Service
07 Left against medical advice or discontinued care
08 Discharged/Transferred to Home under care of Home IV Service [deleted 10/1/2005]
09 Admitted as an inpatient to this hospital (more than 3 days after related outpatient
services or admission is unrelated to outpatient services)
20 Died
21 Discharged/Transferred to Court/Law Enforcement [added 10/1/2009]
30 Still a patient or expected to return for Outpatient Services
40 Died at home (Hospice claims only)
41 Died in a medical facility (Hospice claims only)
42 Died at unknown location (Hospice claims only)
43 Discharged/Transferred to Federal Health Care Facility (e.g. DOD, VA) [added
10/1/2003]
50 Discharged/Transferred to Hospice care- Home
51 Discharged/Transferred to Hospice care - Medical Facility
2
61 Discharged/Transferred to Hospital-based Medicare approved Swing Bed [added
10/1/2001]
62 Discharged/Transferred to Inpatient Rehabilitation Facility or Hospital
Rehabilitation Unit [added 10/1/2001]
63 Discharged/Transferred to LTC (Long Term Care) Hospital [added 10/1/2001]
64 Discharged/Transferred to Nursing Facility - Medicaid Certified [added 10/1/2002]
65 Discharged/Transferred to Psychiatric Hospital or Hospital Psychiatric Unit [added
10/1/2003]
66 Discharged/Transferred to CAH (Critical Access Hospital) [effective 1/1/2006]
70 Discharged/Transferred to another type of health care institution not defined
elsewhere in the code list [effective 4/1/2008]
71 Discharged/Transferred for Outpatient Services - another Facility [10/1/2001 -
9/30/2003 only]
72 Discharged/Transferred for Outpatient Services - this Facility [10/1/2001 - 9/30/2003
only]
Debarred Provider - Payment Reason Code– (See Field # 54)
C OPM has approved payment. Member is receiving continuing care.
D Denied [no payment, after 15 day grace period]
G Claim is within 15 day grace period.
M OPM has approved payment. Member resides in a Medically Underserved Area.
U Claim was paid, unknown reason.
X OPM has approved payment. Other/unspecified reason.
blank not applicable - not a debarred provider (Do not add the actual word “blank”.
Please leave the field empty).
Medicare Payment Disposition Code – (See Field # 59)
A Medicare Part A or Medicare Prepaid/Advantage Plan payment
B Medicare Part B or Medicare Prepaid/Advantage Plan payment
C Medicare Part A and Part B payments [ended 12/31/2005]
C Medicare Part D Prescription Drug Coverage payment [effective 1/1/2006]
D all charges applied to Medicare Part B Deductible, no Medicare payment
E Medicare Part A Benefit Period is Exhausted, no Medicare payment
F Not a Medicare Part A or Part B or Medicare Prepaid/Advantage Plan Benefit, no
Medicare payment
G all charges applied to Medicare Part A Deductible, no Medicare payment
H Provider is not covered by the Medicare Prepaid/Advantage Plan, no Medicare
payment
J Medicare Part A or Part B multi-line pricing; Medicare payment is indicated on
another charge line
K No Medicare Part A benefit available, Medicare Part B provided payment
N Not enrolled in the Part of Medicare that would cover this service, no Medicare
payment
P Speculative Medicare
U Medicare Part A and/or Part B payment (Unable to distinguish)
X Medicare Part A and/or Part B priced the claim but the carrier is unable to
determine why there was no Medicare payment.
3
blank not enrolled in Medicare (Do not add the actual word “blank”. Please leave the
field empty).
Carrier - Paid Indicator (HIPAA codes) – (See Fields #60, 62)
16 Medicare Fee-for-Service/Advantage Plan
BL Other BlueCross BlueShield
C1 Other Commercial Care
MA Traditional Medicare (Part A)
MB Traditional Medicare (Part B)
MU Traditional Medicare (Unable to determine whether Part A and/or Part B)
NF No Fault Insurance
SP Speculative
SU Subrogation
WC Workers Compensation
blank this carrier paid as primary-(Do not add the actual word “blank”. Please leave
the field empty).
. Pricing Method– (See Fields #60, 66)
4 Percentage of Technical Amount Paid - applied after appropriate savings have been
deducted from the Total Covered Charges, but prior to the application of any
deductible and/or coinsurance.
5 Dental Fee Schedule Allowance (Rate X the Number of Services)
6 Maximum Allowable Charge (MAC) - deductible and/or coinsurance applied to the
MAC Amount.
B Percentage of FEP Allowable Charges - applied after appropriate savings have been
deducted from the Total Covered Charges, but prior to the application of any
deductible and/or coinsurance.
D Percentage of Total Covered Charges - applied directly to the Total Covered
charges prior to the application of appropriate savings, deductible and/or
coinsurance.
E Per Diem (Rate X the Number of Days) - deductible and/or coinsurance applied to
the lesser of the Per Diem Amount or the Total Covered Charges. Applies only to
inpatient claims.
F Medical Fee Schedule Allowance (Rate X the Number of Services)
G Diagnostic Related Group (DRG) Price Amount - deductible and/or coinsurance
applied to the lesser of the DRG Amount or the Total Covered Charges. Applies
only to inpatient claims.
I Encounter/Capitated Service - the service reported on this charge is considered
encounter data as it is covered by a set fee paid to the provider regardless of
whether or not services are rendered. No disbursement will occur as a result of this
charge.
K Per Diem (Rate X the Number of Days) plus any deductible and/or coinsurance -
Deductible and/or coinsurance is calculated on the Per Diem allowance to determine
the amount the provider agreed to accept as payment in full. Applies only to
inpatient claims.
L Percentage of Total Charges All Services - applied directly to the Total Charges All
Services prior to the application of appropriate savings, deductible and/or
coinsurance.
4
M Percentage of Negotiated Allowance - applied after the primary pricing method has
been used to reduce the Total Covered Charges, but prior to the application of any
other savings, deductible and/or coinsurance amounts.
N Percentage of Amount Paid Special Formula - the Pricing Percentage is applied
after any non-covered amount, deductible and/or coinsurance has been deducted
from the Billed Charges.
U Unspecified - the specific pricing method is not available.
V Priced by Vendor - such as PPO Provider Networks, etc. This should be used if it
was priced by a vendor and do not know what method the Vendor used.